Third Party Consent to Allow Access to Medical Information

Please complete this form if you wish to grant a representative the ability to communicate with us about you.

This will enable them to gain information about you and your medical problems, talk to us about your care, and give and receive information about you. It will not entitle them to order copies of your medical records, sign consent on your behalf, withdraw care or sign an order to prevent your resuscitation.

Giving consent to someone else to communicate with us about you and your medical problems is a very significant step and you should give it serious consideration before you give consent. You need to consider what they might learn about you and your problems that you did not want them to know and have fully considered the ramifications of giving that consent. Once they learn information about you, they might also share it with others that you did not intend to have that information.

If you are unsure about giving consent, we advise that you do not give it and that you seek legal advice before proceeding.

Third Party Consent

Third Party Consent

Your Details

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Your Representatives Details

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Do you need to add the details of any further representatives? *

Your Representatives Details

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Do you need to add the details of any further representatives? *

Your Representatives Details

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Declaration

I consent to the release of confidential information from my medical record as stated in this form to the person(s) stated above.